Health reform: The debate goes public

Commissioned by Philips

Health reformThe debate goes public

The third report in a series of four from the Economist Intelligence Unit

© Economist Intelligence Unit Limited 2009


1

Preface 2

Executive summary 5

In search of the grand bargain 7

The need for reform 8

A unique opportunity in the US 10

Germany: post-reform pessimism 10

Prodding an elephant in the UK 13

A new role for citzens 15

Citizens as consumers of healthcare 16

The rise and rise of citizen advocacy 16

But what do they want? 19

Steps forward for patients in the UK 22

Indian healthcare: seeking a new route 22

Conclusion—Policymakers’ grand bargain 25

Appendix: Survey results 27

Contents



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Health reform: The debate goes public is an Economist Intelligence Unit report commissioned by Philips, the third in a series of four to be published in 2009. The Economist Intelligence Unit

bears sole responsibility for the content of this report. The fi ndings and views expressed within do not necessarily represent the views of Philips.

Our research drew on two main initiatives. l In June and July 2009 we conducted a major survey of citizens across four key economies: the US, UK,

Germany and India. In total, 1,575 respondents took part in the survey, with an equal gender split. All respondents were of working age, with the sample including full- and part-time employees, students, the unemployed and retirees.

l To supplement the survey results and help interpret their implications, we also conducted in-depth interviews with numerous leading fi gures in the healthcare sector, including policymakers, practitioners and other experts.

Of the respondents, 481 were in the US, 461 in Germany, 360 in the UK and 273 in India. The survey sought to be broadly representative of each country’s population, across a range of age groups, levels of education and employment status. In the case of India, most respondents fell into the 18-55 age group, with only a small percentage aged 56 and over. Similarly, in line with demographic trends, the US cohort included the largest proportion of respondents aged 56 and over. Almost 40% of US and UK respondents, and 23% of Germans, were retired.

The report was written by Julie Sell and edited by Iain Scott and Gareth Lofthouse. We would like to thank everyone who participated in the survey, and all the interviewees, for their time and insight.

Preface



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Eric Odom—Executive director, American Liberty Alliance (US)

Dr James Rohack—President, American Medical Association (US)

Sophia Schlette—Health programme director, Bertelsmann Foundation (Germany) and senior international advisor, Kaiser Permanente Institute for Health Policy (US)

John Castellani—President, Business Roundtable (US)

Dr Richard Freeman—Professor, University of Edinburgh School of Social and Political Science (UK)

Monika Sood—Vice-president of corporate advisory services, Feedback Ventures (India)

Kavita Ramdas and Anasuya Sengupta—CEO and President, and Asia and Oceania programme director, respectively, The Global Fund for Women (US/India)

Professor John Appleby—Chief economist, The King’s Fund (UK)

Dr Peter Reader—Clinical director, Humana Europe (UK)

Stefanie Ettelt—Research fellow, London School of Hygiene and Tropical Medicine (UK)

Mary Wilson and Betsy Lawson—President and senior lobbyist, respectively, League of Women Voters (US)

R T Rybak—Mayor of Minneapolis, Minnesota (US)

Professor Laura Carstensen and Jane Hickie—Director and senior research scholar, respectively, Stanford University Centre on Longevity (US)

Jenn Brown—Minnesota state director, Organizing for America (US)

Ted Marmor—Emeritus professor of public policy and management, Yale University (US)

Interviewees



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Executive summary

Healthcare systems are complex, enormous and unwieldy, whether they are state-managed monoliths such as the UK’s, or dominated by the private insurance sector, as in the US. They are traditionally

slow to adapt to change, but now those immovable objects are being forced to confront not just one, but several irresistible forces: demographic (ageing populations), epidemiological (increasing incidence of chronic diseases), technological (more expensive drugs and technologies) and economic (global recession, high public debt, smaller pensions). The price for ignoring these forces could be disastrous—the US president, Barack Obama, has warned that if it is allowed to continue down its present course, the US healthcare system will bankrupt the entire country.

Try telling the end-users of healthcare about these pressures, and they will be nonplussed. In a major survey for this report, the Economist Intelligence Unit set out to ascertain just what the citizens in four large economies—the US, UK, Germany and India—think about their healthcare systems. The fi ndings show clearly the kinds of dilemmas faced by healthcare policymakers who seek to implement reforms.

The starkest example emerges when respondents were asked in basic terms about their expectations for choice and cost in healthcare. Globally, 83% of respondents say that they would prefer to shop between a range of options in order to get the best treatment. At the same time, however, more than half say that they are not prepared to pay more to get a better healthcare service, whether in the form of taxes, fees at point of provision or fees to insurers. Consumers want choice—but are not prepared to pay for it.

Our survey shows that citizens’ expectations for healthcare are high—not just in developed countries, which have been used to high standards of care, but also in developing countries such as India, where people are becoming accustomed to better standards. They want access to the latest treatments, timely, affordable care, and a range of choices. They are better informed than ever about their health and their treatment options. They are prepared to take some responsibility for their own health, but broadly they do not want to have to pay a lot more than they already are for their healthcare. If they are unhappy with aspects of their healthcare, they largely lay responsibility at the feet of their governments.

Key fi ndings from the survey include the following:

l Governments get a thumbs-down on their handling of healthcare. Not surprisingly, the economy and jobs are seen by respondents as the most important issues for their government, but healthcare takes second billing in the US, Germany and India—ahead of education, the environment, crime, defence and housing. In the UK it comes third, after crime, but 29% of Britons are generally more inclined to agree



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that their government has the right approach to healthcare. By contrast, just 8% of Germans think their country is on the right track, whereas 62% think their government has the wrong approach, as do nearly half of American respondents.

l If patients are now customers, they are not happy ones. When it comes to healthcare, Americans, arguably, have more choices than citizens of most other countries. However, when asked to indicate their levels of satisfaction with a range of aspects of healthcare (such as waiting times, quality and availability of care and doctors, cost of treatment and medicine), almost one-quarter of Americans say they are not satisfi ed with any. That was an even higher fi gure than in the UK (15%), where patients have far less choice. That does not mean Americans believe they receive poor-quality care—compared with other countries, more US respondents are satisfi ed with the quality of their doctors, with waiting times and with general quality and availability of healthcare—but the fi nding does indicate a high level of general dissatisfaction. Strikingly, about one in fi ve respondents across the global sample say they are not satisfi ed with any aspect of their country’s healthcare system.

l Some patients are more empowered than others. Only one-quarter of UK respondents feel they have much control and infl uence over where and how they are treated, compared with 64% of Americans. Nearly 60% of British respondents say that they are not encouraged to choose from a range of doctors or hospitals for their treatment. The UK government’s recent about-face, allowing patients to choose between public and private healthcare, without losing access to the National Health Service (NHS), appears to be a welcome one—three out of four respondents say that they would compare services to get the best possible treatment. Meanwhile, US residents are more optimistic (74%) than those in the UK (61%) or Germany (38%) that they will get prompt, effective treatment if they become ill. Some 74% of Americans, however, say they are concerned about being able to afford that treatment—far more than Germans (55%) or Britons (50%).

l Britons are not keen on fees, but are more relaxed about tax. UK citizens are less keen than people elsewhere on the idea of paying fees at the point of provision (co-payments), or to insurers, for an improved healthcare service. However, the survey found that more Britons (27%) would be willing to pay higher taxes for improved healthcare services than would Americans (15%) or Germans (9%). Meanwhile, nearly 45% of Britons say that they would not be willing to pay anything extra, compared with 61% of Americans and 64% of Germans. The British are also wary of the notion that greater private-sector involvement would improve the country’s healthcare system, perhaps not surprising given that private healthcare takes up a relatively small amount of the country’s healthcare expenditure.

l German gloom spells a warning to reformers. Germany began reforming its healthcare system a decade ago. Since then, according to Economist Intelligence Unit data, Germans are living longer and pay less for their healthcare than many of their neighbours. However, German citizens’ doubts about their healthcare system permeate the survey, just as German healthcare professionals revealed their pessimism in a separate Economist Intelligence Unit survey earlier this year1. Far fewer German citizens (38%) than



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those elsewhere are optimistic that they will get prompt, effective treatment, more than half are worried about the costs of getting treatment, and far more (79%, compared with 57% in the UK and 36% in the US) feel their healthcare professionals are working too many hours to be effective.

In search of the grand bargainAgainst all this, policymakers are fl oundering to come up with solutions. They need to fi nd a way to strike a grand bargain with patients, who are no longer simply passive recipients of care, but increasingly active consumers of health services.

The key issue is not necessarily one of knowing which reforms to implement. No matter how sensible reform plans may sound, there is generally one important stakeholder who remains unconvinced: citizens. There is a big gap between policymakers and consumers when it comes to appetite for health reform. The fi rst group sees it as an essential way to relieve fi nancial and social pressures, while the second is afraid that they might lose what they currently have. Consequently, selling healthcare reform is not a task for the faint-hearted. Even Mr Obama, who campaigned successfully on the issue in his presidential campaign, has struggled in his bid to implement a fairer system in the US. The example of Germany—which implemented major reforms a decade ago, but whose citizens remain broadly pessimistic about their healthcare and distrustful of those who manage it—serves as a warning to would-be reformers.

If they are to be successful, policymakers must be prepared to be thick-skinned and patient, and to avoid quick fi xes. The results of broad-based reforms are unlikely to be seen overnight: South Korea’s plan to introduce universal healthcare coverage began in 1977, and is still being developed today. The UK has pumped millions of extra pounds into its NHS in the last decade, but it may be that the country’s more subtle reform strategies, such as patient-reported outcome measures, will be the ones that have most impact on cost containment and patient satisfaction in the long term.

1. Fixing healthcare: The professionals’ perspective, Economist Intelligence Unit, March 2009.



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For all the different permutations in healthcare systems around the world, policymakers face several broadly similar challenges: spiralling costs and increased demand are putting these systems

under growing pressure, just as the worst economic downturn in decades is stretching budgets even thinner. The need for healthcare reform is evident and in some countries, including the US and the UK, increasingly urgent.

Unless major changes are implemented soon, President Obama has suggested, escalating healthcare costs could severely cripple—or even bankrupt—the world’s biggest economy. In the UK, the NHS Confederation, an independent body representing healthcare organisations, has warned that the National Health Service (NHS) could face real-term funding reductions of up to £10bn (US$15.5bn) from 20112.

For political leaders grappling with tight budgets in a fi nancial downturn, health is simply too big an issue to ignore. Healthcare is forecast to account for a whopping 16.3% of GDP in the US in 2009, about 10.6% of GDP in Germany and 9.9% of GDP in the UK. Even in India, a country long criticised for under-investing in health and social services, the World Health Organisation (WHO) forecasts that healthcare will account for about 5% of GDP in 2009.

Demographic changes compound the problem. Population growth in many countries—not least India—is exacerbated in the US and UK by an ageing population. The wave of “baby boomers” (those born roughly between 1945 and 1960) is moving towards the inevitable increase in health problems that come with age. Germany, which faces a population decline, is confronted with an even starker demographic picture as the ratio of senior citizens to young workers steadily climbs.

Yet unlike other complex policy topics facing political leaders, healthcare is also an intensely personal issue. The emotional response from many Americans to the healthcare reform debate in recent months is in part the result of their personal circumstances. More than 45m people across the country—many of them in working families—lack health insurance and the problem is escalating. According to a report by Families USA3, more than 44,000 people in the US are losing health coverage each week, equating to some 2.3m each year. Without healthcare reform, the report estimates, 6.9m more Americans will lose health coverage by the end of 2010.

“The status quo is not acceptable,” says James Rohack, a cardiologist who serves as president of the American Medical Association (AMA), the nation’s leading physicians’ group. In addition to endangering individuals’ health, the gaps in health coverage have knock-on effects on the wider system: growing

The need for reform

2. Dealing with the Downturn, The NHS Confederation, June 2009.3. The Clock Is Ticking: More Americans Losing Health Coverage, Families USA, July 2009.



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numbers of uninsured people turn up at hospital emergency rooms to be treated, for instance, an expensive solution that is driving up healthcare costs for the majority of Americans who are insured.

Even in countries with universal health coverage, there is a clear public concern about healthcare. A survey of citizens across four countries conducted for this report reveals that if people were asked to vote tomorrow, they would rank healthcare as one of their top priorities for government—second only to the economy and jobs in the US, Germany and India. In the UK, healthcare is the third-highest priority of those polled, behind the economy and crime.

While people in the US and the UK are generally optimistic that they would receive prompt and effective treatment if they or a family member were to become seriously ill, the survey reveals that many people have doubts about their governments’ approaches to healthcare. Among those surveyed, Germans were the least likely to have confi dence in their government’s approach (see box Germany: post-

reform pessimism).

If you had to vote tomorrow, which of the following issues would be most important to you, in terms of your government’s priorities? Please select up to two.(% respondents)

Economy and jobs

Healthcare

Crime

Education

Environment and climate change

Defence and terrorism

Other

Housing

None of the above

I do not have an opinion

17

65

15

41

13

13

1

1

6

3

Source: Economist Intelligence Unit survey, July 2009.

If you or a member of your family fell seriously ill, how optimistic are you that they would receive prompt and effective treatment?(% respondents)

42

US Germany UK India

Very optimistic

Somewhat optimistic

Neither optimisticnor pessimistic

Somewhat pessimistic

Very pessimistic

Don’t know what qualityof treatment would

be received

32

10

9

3

4

30

8

33

16

6

7

42

19

22

12

4

1

35

44

9

4

1

4




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For all their similarities in this time of fi nancial crisis, the political environment for healthcare reform in each country is also shaped by unique pressures and processes. These range from political structures to economic realities as well as cultural and social mores. A closer look at the situation in the US and UK, two countries facing national political elections in 2010, illustrates why healthcare reform will be driven by characteristics particular to each country.

USA

Germany

UK

India

How strongly do you agree or disagree with the following statement? My country’s government has the right approach tohealthcare (% respondents)

427

430

223494

332662

2122532227

11118303010

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know


Germany: post-reform pessimism

German consumers’ mistrust of their country’s healthcare system emerges clearly when they are asked whether they agree that their government has the right approach to healthcare. Fewer than one in ten agree, whereas nearly two-thirds disagree. This makes Germans, on aggregate, even more disgruntled than American citizens, where half disagree that the US government is on the right track.

Yet Germans’ general pessimism about their healthcare system does not necessarily match the reality of healthcare in the country, when compared with other regions. The country’s healthcare expenditure has been a respectable 10% of GDP (an estimated US$331bn in 2009) for the last fi ve years. Over that time, average life expectancy has increased from 78 to 79 years, higher than

the UK. There are about eight hospital beds for every 1,000 people, more than in the US or the UK, and a German’s visit to the doctor for a check-up is more affordable than in many other countries (see chart).

So why the complaining? The main difference between Germans’ experience and that of comparable economies is that they have already gone through signifi cant healthcare reforms. Germans are now expected to have to pay for some of their own healthcare—a €10 fee when they pick up a prescription, for example. Even so, their co-payments are among the lowest in Europe. As Sophie Schlette of the Bertelsmann Foundation points out, however, Germans are not comparing their healthcare with that of their neighbours, but to what they had before.

More reforms need to be made to the German healthcare system, no doubt leading to further mistrust from end-users. If

benchmarks such as life expectancy are any guide, though, the German experiment could well prove to be an enduring model for others to follow.

Average cost of routine check-up at family doctor

UK

US

Japan

France

Germany

Sweden

India

260

225

105

97

85

23

17

Economist Intelligence Unit Worldwide Cost of Living Survey.

Price (US$) % of monthly personal disposable income

11.0

7.6

5.6

3.7

3.5

1.0

25.7



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A unique opportunity in the US?A confl uence of pressures is driving the push for healthcare reform across America. President Obama made it one of his signature campaign issues during 2008. His election victory, based in part on the support of millions of Americans who had never voted before, gave him a stronger mandate for change than any US president had enjoyed for years.

Mr Obama’s campaign proposals to overhaul the US healthcare system fell into two broad categories: plans to improve medical practices and health outcomes (through emphasis on preventive medicine, payment reforms, wider adoption of electronic information systems, and research on the comparative effectiveness of specifi c diagnostic and treatment approaches), and plans to restructure the health insurance market (through creation of a new public insurance option, adoption of an insurance marketing exchange, and new regulations to cut insurance administration costs). It was an ambitious agenda.

Yet the structure of America’s political system—a division of powers that gives Congress signifi cant independence and weight vis-à-vis the executive branch—as well as Mr Obama’s tactical decision once in offi ce to let Congress craft the specifi c details of a health reform bill, have complicated his reform efforts. This strategy comes with its own challenges, including catering to the concerns of infl uential lawmakers in a highly partisan policymaking process. Even within his own party, so-called Blue Dog Democrats have broken from the leadership on key reform issues.

Lawmakers are particularly sensitive to projections about the impact that various healthcare reform proposals may have on a rising federal defi cit. “It’s not good enough that [reform is] just paid for,” senator Mark Warner of Virginia told the Washington Post in August. “It actually has to start driving long-term costs down.”

Ted Marmor, an emeritus professor of public policy and management at Yale University, says the key role that Congress is playing in the reform debate results in an abundance of “veto points” in the US political system that do not exist in parliamentary democracies such as the UK or Germany, making agreement harder to achieve.

The division of political power also provides openings for special-interest groups—ranging from pharmaceutical companies to hospital owners—to infl uence the policy-making process at multiple points. This fact, combined with the competitive and highly fragmented nature of the US healthcare market (among both providers and payers) has fuelled an explosion of lobbying in Washington and 50 state capitals, where state lawmakers also play a role in setting rules for healthcare in their individual jurisdictions.

The Center for Responsive Politics (CRP), a group that tracks lobbying activity, reported that the healthcare industry spent more dollars lobbying national politicians in 2008 and the fi rst part of 2009 than any other sectors, including fi nancial services and energy4. Spending continued to rise as the debate heated up. Last year, CRP reported that healthcare interest groups spent a huge US$484.7m on lobbying—more than any other sector.

An important element driving the healthcare debate this year is the fact that key lobbying groups, ranging from big business to hospitals and physicians, have backed calls for change more forcefully than ever before. Pharmaceutical companies and hospital groups are among those that offered concessions early 4. www.opensecrets.org/lobby/index.

php



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in the negotiations over reform. Some credited Mr Obama for convening a series of White House summits on healthcare to bring together long-time adversaries, but pragmatic self-interest is clearly a prime motivator for these stakeholders—and they are far from united on the specifi cs of what needs to be done.

For Business Roundtable, a group representing chief executives of some of the largest US corporations, “healthcare is the biggest single cost pressure our members face”, says its president, John Castellani. His members’ companies—which include giants such as Boeing, DuPont, Microsoft and Motorola—are responsible for the healthcare coverage of about 35m people. Increasingly, they are being hampered by high healthcare costs that their foreign competitors do not face. Reform is necessary, they argue, to keep US business competitive internationally. In Mr Castellani’s view, the confl uence of factors in favour of healthcare reform is “greater now than it has been at any time in the history of our country”.

The AMA, which has been blamed in the past for obstructing meaningful reform, is also advocating change. “The demographics say the status quo won’t work,” says Dr Rohack, the group’s president, noting that a wave of baby boomers will soon be eligible to collect Medicare, which provides health insurance cover to people over the age of 65. He also predicts the severity of health problems, from obesity to diabetes, will continue to grow. “As physicians, we know what the disease burden is, coming down the pike,” he adds.

Part of the current frustration in the US stems from the fact that, for all it is spending on healthcare—far more per head than other rich countries such as the UK and Germany (see chart below)—the US performs worse in certain key health measures, such as average life expectancy or infant mortality rates, than countries that spend less5. Yet in other measures, such as cancer outcomes, the US performs relatively well. The McKinsey Global Institute, a consultancy, found that based on 2003 data, US healthcare spending was US$477bn above what would be expected from comparable OECD countries.

Worlds apartHealthcare spending per head, US$

Country 2004 2005 2006 2007 2008

US 6,049 6,385 6,756 7,236 7,553

Germany 3,533 3,622 3,675 4,216 4,692

UK 3,057 3,258 3,589 4,225 4,100

India 32 37 41 50 53

Source: Espicom; OECD; WHO; Economist Intelligence Unit, World Development Indicators.

Dr Rohack of the AMA blames some of this on high administration costs (derived from dealing with more than 1,500 insurance companies) and a legal system that he deems hostile to doctors who feel compelled to practice “defensive medicine”—in which doctors prescribe medical tests and procedures that may not be necessary, purely to guard against malpractice lawsuits. McKinsey reports that reducing incentives for the practice of defensive medicine could save as much as US$50bn per year in the US with minimal impact on quality of care6.

While more stakeholders in the US healthcare system are advocating reform this year than at any time in the past, the fi nger-pointing between them—physicians blaming insurers and lawyers, insurers blaming drugmakers, and so on—is unlikely to be resolved anytime soon.

5. US Census Bureau and OECD data.

6. McKinsey Global Institute, Accounting for the Cost of US Healthcare, November 2008.



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Untangling exactly what makes the US system so expensive, vis-à-vis other countries in the developed world, is part of the challenge. McKinsey found that outpatient care (including same-day hospital visits) is the biggest and fastest growing part of the US health system, accounting for US$436bn, or two-thirds of the spending that is above the OECD average. Reasons for these ballooning costs range from an increase in provider capacity because of the profi tability of such procedures, costly new technologies, and a large group of patients who are fairly insensitive to price, because of so-called “gold-plated” insurance coverage that limits out-of-pocket costs.

Timing will be a critical factor in determining whether and how healthcare reform survives the US political process, as the window to achieve meaningful reform will not be open forever. Further delays will give opponents more time to “stir up public anxieties”, as the former US secretary of labour, Robert Reich, puts it7. Furthermore, congressional elections are looming in November 2010, so lawmakers running for re-election may be less inclined to make hard political choices that could upset voters.

Yet others with signifi cant infl uence in Washington are in less of a hurry. Mr Castellani, of Business Roundtable, urges care and caution. “We understand the political process, we know it is not smooth,” he says. “It’s more important to get it right than to be quick.”

Prodding an elephant in the UKIf the US political environment surrounding healthcare reform looks a bit like the Wild West to European eyes—replete with agitated citizens attending town-hall meetings carrying loaded fi rearms—the British reform scenario might be likened to policymakers prodding an elephant to perform. The NHS is big, grey, and reasonably well-liked, but also increasingly costly to maintain and slow to change direction.

The vastness of the NHS, which turned 60 in 2008, is hard to overstate. With about 1.5m staff, it is Europe’s largest employer and is responsible for the overwhelming majority of healthcare delivered in the UK today. Because the private healthcare system has not yet achieved a scale suffi cient to pose a major competitive threat to the NHS, any efforts to get a handle on healthcare reform in the country must tackle this giant.

The social principles that underpin the NHS—that it is funded by taxpayers and available free of charge to everyone—make it intimately connected to government, both fi nancially and politically. In the past, when the economy was booming, the spending issue was less politically delicate than it is today. Lord Darzi, a surgeon who served as UK minister of health until submitting his resignation to the prime minister, Gordon Brown, in mid-2008, noted earlier this year: “The government has signifi cantly increased the expenditure in the NHS from somewhere around £42bn in the year 2002 to somewhere approaching £110bn next year. That’s massive growth.”

Now, though, the NHS’s fi nancial future looks signifi cantly less rosy, thanks to the dire state of the public fi nances. A recent report by The King’s Fund, a London-based research centre focused on health policy, and the Institute for Fiscal Studies described prospects for future funding of the NHS as “bleak”8.

“The fi nancial crisis is estimated by the Treasury to have dealt a permanent blow to the size of the UK economy, with a signifi cant knock-on impact on the strength of the public fi nances,” wrote Professor John Appleby, chief economist at The King’s Fund. “Given this, it is hard to see how the next spending review—which might not report until after a 2010 general election—could unveil further real-term increases in

7. Robert Reich, The future of universal healthcare, Salon.com, July 27th, 2009.

8. The King’s Fund and The Institute for Fiscal Studies, How Cold Will It Be? Prospects for NHS Funding: 2011-17, July 2009.



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the NHS budget without signifi cant reductions in spending elsewhere, or the introduction of tax-raising measures. The fi nancial future remains uncertain, and will depend on the nature and path of the economic recovery, particularly the extent to which this boosts tax revenue and reduces spending pressures through lower debt interest payments or falls in unemployment.”

Managers within the health service are equally concerned. “The NHS is facing a severe contraction in its fi nance with an £8bn-10bn real-terms cut likely in the three years from 2011,” the NHS Confederation report stated in June 2009, calling this “the most severe leadership challenge the NHS is ever likely to face”. It predicted that the government healthcare system “will not survive the impending spending squeeze unchanged”.

Therein lies a dilemma for public policymakers: a general sense among the public that the NHS as an institution is doing a decent job, despite grumbling about various elements of it, makes it something of a political hot potato. “For the public, the NHS is not quite untouchable but it is very well-supported,” says Professor Appleby.

As a result, in the run-up to a general election that Mr Brown must call before June 2010, the two major political parties—Labour and the Conservatives—are keeping quiet about the details of their funding proposals for the NHS in years to come. “It’s a case of the main parties inching towards an admission that at very best the NHS will receive little or no extra real funding”, says Professor Appleby. The fact that Labour—after more than a decade in offi ce—has fared poorly in public opinion polls this year, with the Conservatives looking relatively strong, gives neither side an added political incentive to reveal detailed spending plans beyond hinting that past levels of NHS funding cannot be guaranteed.

The centralised nature of the UK parliamentary system—the prime minister has a much greater degree of control over government decision-making, not to mention its own party members, than a US president does—is also signifi cant, giving Mr Brown tighter control over healthcare spending and policy than Mr Obama has. The UK system means that a government “can convert sentiment into action more readily”, says Professor Marmor. “If a bedpan falls in Leeds, the secretary of state has to answer for it in parliament.”

Yet in contrast with the US—where fundamental questions about who needs health coverage and the nature of public versus private markets is being hotly debated by politicians—the debate in the UK (not to mention other countries in Europe) is now more muted. Dr Richard Freeman, professor at the University of Edinburgh, author of a book on the politics of health in Europe, says that “the big politics of healthcare are about establishing and maintaining universal coverage. Beyond that, it’s as much about competence as ideology.” In his view, there are no great ideological differences at the moment between the UK’s two major parties on the NHS. “It’s about competence rather than ideology.”



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An email from the US president, Barack Obama, to millions of Americans on August 5th 2009, made it clear that he thinks citizens should be at the heart of the US healthcare debate. The message,

echoing his presidential campaign last year, read in part: “This is the moment our movement was built for. For one month, the fi ght for health insurance reform leaves the backrooms of Washington, DC, and returns to communities across America.”

What has ensued is one of the most intense public debates about a US policy issue in recent years. As lawmakers returned to their home districts for the August recess to gauge the mood of citizens, heated arguments, shouting matches and violence broke out at some of the town-hall meetings they had organised. In 2009 it is clear that any US politician who ignores public sentiment on healthcare reform does so at his or her peril.

Personal experience plays a powerful role in shaping the public debate. “Healthcare is simultaneously a complex issue and one of the most personal issues you could lobby on … everybody has a healthcare story,” says Betsy Lawson, a Washington lobbyist with the League of Women Voters who has worked on healthcare issues for decades.

Is the public anger shown at some town-hall meetings justifi ed, however? “Absolutely, it’s justifi ed,” says Eric Odom, executive director of a libertarian group called American Liberty Alliance (ALA), members of which advocate a more limited role for government in areas ranging from healthcare to offshore oil drilling. “This is a very emotional and passionate issue.” (See box, The rise and rise of citizen advocacy)

The US public debate has, in turn, sparked an outpouring of public sentiment in the UK, including more than 1m people following a Twitter campaign supporting the National Health Service (NHS). Much of it is in response to American criticisms about how the UK’s health service is run. The UK prime minister, Gordon Brown, and his wife, Sarah, showing a growing awareness of social networking as a political tool, joined the Twitter campaign in early August. The NHS “often makes the difference between pain and comfort, despair and hope, life and death,” Mr Brown wrote, adding “thanks for always being there” in his post on Twitter’s “welovetheNHS” feed9 .

Indeed, new technologies are truly changing the way citizens and lawmakers communicate on public-policy issues, including healthcare. A visit to the White House website in mid-August revealed a string of blog postings about healthcare, including news that the site was offering “La Realidad: the truth about health insurance reform”, in Spanish. There was also a video of Mr Obama’s weekly address to the public, talking about healthcare reform, and a place to sign up for regular updates through seven different social

A new role for citizens

9. http://news.bbc.co.uk/2/hi/uk_news/politics/8199615.stm



16

network tools (including Twitter, Facebook and MySpace). Lawmakers and their national parties are similarly jumping on the technology bandwagon.

Meanwhile, numerous special-interest groups and activist organisations have embraced new technologies, in efforts to infl uence the policy debate. From upstarts like the ALA to established groups like the AARP (formerly the American Association of Retired Persons) and the American Cancer Society, the result has been a signifi cant increase in involvement on policy reform discussions.

On a more personal level, especially within the US, patient groups offering advice and support on topics ranging from cancer care to diabetes and mental health have connected people across vast distances and given them the ability to inform themselves and organise as never before. Many of these groups are less focused on change than on patient information, but they too have had an impact on the healthcare system.

Citizens as consumers of healthcareThe political drama of 2009 masks a broader trend: citizens increasingly see themselves as consumers who want to make choices about their healthcare. Health-related websites, publications and support groups have proliferated in recent years. Patients today go in to see their doctors armed with questions

The rise and rise of citizen advocacy

The emotionally charged debate over US healthcare reform has prompted advocacy groups across the political spectrum to target citizens who, they hope, will in turn back different reform proposals. The surge in volume of emails, calls, petition signatures and other contact with lawmakers during the summer congressional recess illustrates how profoundly such organisations are shaping the debate, and how divided public opinion remains.

Amid the bustling weekend farmers’ market in Minneapolis, Minnesota, a group called Organizing for America spent a weekend button-holing people for their signatures on a petition in favour of the healthcare reform platform put forward by the US president, Barack Obama. The group, an offshoot of the Democratic National Committee, was advocating three broad principles: reducing healthcare costs;

guaranteeing choice (including “a public insurance option”); and ensuring quality, affordable care for all Americans.

Swapan Chakraborty and his wife Sunita, loaded down with shopping and children, stopped to sign the petition. Born and raised in India, they lived and worked in Germany for three years before emigrating to the US. Mr Chakraborty, a research engineer, did not hesitate when asked which of the different healthcare systems he prefers. “Europe is best,” he said. “Healthcare is a fundamental right. It’s like your home. It should be separated from your job.” His wife, an assistant bank manager, chimed in on the US system: “Everyone should be able to afford it”.

Both husband and wife said they would be willing to pay higher taxes for a public health option. This position, however, is out of tune with the majority of the respondents to our citizen survey, who are not willing to pay more for improved healthcare (see chart).

Throughout the weeks of public debate over healthcare, Organizing for America has employed a combination of old and

new-style campaign tactics to mobilise citizens to back the president’s broad reform principles. In late July, for instance, more than 1,000 people turned out for a free barbeque at a healthcare gathering put on by the group’s Minnesota branch. The same petition that the Chakrabortys signed was circulated and people were urged to write to their lawmakers. “The response was

In which ways would you be most willing to pay (more) for an improved healthcare service? Select up to two.(% respondents)

17

Increased taxes

(Increased) fees at the point of provision

(Increased) fees to healthcare insurer

None of the above: I am not willing to pay more

I have no opinion

17

16

8

52




17

overwhelming,” says Jenn Brown, state director for the group that organised the event.

R T Rybak, the Democrat mayor of Minneapolis, drew cheers at the barbeque after he lambasted healthcare lobbyists trying to “protect the status quo” and asked the crowd to “fi ght for the change we need in Washington”. As the audience broke into chants of “Yes we can, yes we can”, Mr Rybak told them “the election was just a start—now we’re part of a movement”. The mayor said later that as a local public offi cial, he cannot afford to ignore the healthcare issue. “Mayors see the consequences of our healthcare system on the streets, in emergency rooms, in schools and in mainstream businesses,” he said. “Any mayor who opens their eyes sees the system is deeply broken, especially for those most in need.”

While groups such as Organizing for America are mobilising citizens broadly supportive of Mr Obama’s reform agenda—including coverage for the uninsured—the American Liberty Alliance (ALA) is working to reduce government involvement in

healthcare and other areas. Its founder, Eric Odom, a 29-year-old computer consultant from Chicago, says the ALA has amassed more than 40,000 email addresses from supporters in the past year, leveraging online social networking sites. Culling and sorting the data by postal codes, he is trying to link local and national organisations that share its principles and notify supporters of opportunities to infl uence the healthcare debate.

“The free-market movement is absolutely our target market,” says Mr Odom. “We want to limit the government’s power as much as possible while getting things accomplished.” In the healthcare debate, that includes opposition to the so-called “public option” for insurance coverage, as well as protection of patient privacy and limits on regulation. Healthcare is just one issue that the group is targeting; others include an end to the ban on offshore oil drilling, lower taxes and opposition to government bailouts for big automakers.

Mr Odom says that one of its greatest successes to date—it was only launched a

year ago—was helping to mobilise more than 800,000 people to attend hundreds of “tea party” rallies across America on April 15th, the day that residents must fi le their tax returns every year. He also cites the congressional decision to ease limits on offshore oil drilling after a campaign that the ALA helped to co-ordinate. “That was a pretty signifi cant victory using only Twitter and Facebook,” he says.

Yet he rejects the suggestion of some Democrats that a network of online advocacy groups with links to the Republican Party and big corporate interests are driving the angry outcries against Mr Obama’s healthcare proposals at town hall meetings across the country. The ALA, he says, has no such formal backing and is merely trying to link like-minded people. “It’s very uncontrolled,” he says of the outcry against reform proposals. “We’d love to take credit for this, but these happened very organically.” As for Mr Odom himself, he says he lives in “a crooked house in Chicago with a train in my backyard”. He doesn’t have health insurance, either. He says he cannot afford it.

and information gleaned from the Internet, creating a dynamic that has greatly altered the paternalistic relationship of old.

Dr Peter Reader, clinical director at Humana Europe and a former manager in the NHS, says the trend in the UK is a logical extension of growing consumerist sentiment in a variety of services, stretching back to the 1980s. Yet the shift presents some serious challenges to a big, relatively monolithic organisation like the NHS. Now people want their healthcare “to fi t them, rather than the other way around,” he says. Humana Europe is currently supporting the NHS with commissioning expertise, service redesign and strategies for improving its patient focus and communication with the public.

The Economist Intelligence Unit’s survey provides insights into what consumers think of their health systems today and what they would like to see change. As noted earlier, Americans are more optimistic than their counterparts in the UK that they or a family member would receive prompt and effective treatment if they were seriously ill, and both groups are more optimistic than their counterparts in Germany.

However, satisfaction levels with various aspects of the health systems vary by country. People in the UK are signifi cantly less satisfi ed than Americans with the time they have to wait for operations and the quality and availability of healthcare in general, but are notably more satisfi ed than Americans with the



18

quality of their physicians, and (less surprisingly) the cost of hospital treatment and drugs. Strikingly, nearly one in fi ve respondents overall say they are not satisfi ed with any aspect of their country’s healthcare system (see chart).

Our survey also shows a willingness by most citizens to take responsibility for their own healthcare, with more than 80% of respondents agreeing with this sentiment in all four countries. The increasingly diverse resources that they consult to obtain health information has helped reduce what the McKinsey Global Institute, a consultancy, has identifi ed as the “information asymmetry” that has traditionally existed in healthcare10. Although doctors remain the most consulted source overall, friends and family, Google, the news media and specialist healthcare sites are all regarded as common sources for health information.

Dr Reader, of Humana Europe, notes that the Internet has made Britons savvier consumers of healthcare information and “many professionals in the NHS still struggle” with this fact. His fi rm is trying to help the health service and its clinicians adapt.

Which of the following aspects of your country’s healthcare system are you satisfied with? Select all that apply.(% respondents)

Waiting times for operations

Quality and availability ofhealthcare informationQuality and availability

of healthcare

Quality of your GP/physician

The cost of medicine

The cost of hospital treatment

State/government-sourcedhealth advice and campaigns

Other, please specify

None of the above

Don’t know

US Germany UK India

46

30

45

52

11

7

5

1

24

6

33

21

28

59

10

12

8

0

20

5

33

18

36

63

27

30

19

1

15

5

35

18

45

32

35

30

24

1

12

3


Which of the following sources do you regularly consult for health information? Select all that apply.(% respondents)

21

My doctor

TV/radio

Magazines/newspapers

Specialist healthcarewebsites

General Internetsearches

My family and friends

Patient groups

Other

67

30

30

35

34

4

4Source: Economist Intelligence Unit survey, July 2009.

10. McKinsey Global Institute, Accounting for the Cost of US Healthcare, November 2008.



19

Of course, part of the challenge with the proliferation of online information, as Dr Rohack of the American Medical Association (AMA) notes, is that “anything can go up on the Internet.” As a result, he says, “The question is ‘are you getting it from a trusted source’?”

McKinsey notes that consumers still face a big “knowledge gap” in healthcare, relative to their care providers. As a result, they still rely heavily on their GPs or physicians for guidance on how to proceed, and even if they have many choices available to them, are ill-equipped to source the most cost-effective care. Because their health is so important to them, they may also be inclined to assume that more care is better care, although this is not necessarily the case.

In addition, while the explosion in new voices in the health discussion and ensuing “noise” is driving the consumerist trend among patients, it is not clear how well this translates into infl uence in the policy arena. Professor Ted Marmor, of Yale University, argues that “we have very poor connectors in America” between public views and policy-making mechanisms. “We’ve got plenty of educated people, but they don’t know what to do with their thoughts.”

Nevertheless, healthcare providers, too, have started to embrace the notion of patients as partners. The NHS Confederation issued a rallying cry in its report earlier this year, suggesting a greater collective responsibility to chart the path forward: “Work to deal with this unprecedented [funding] challenge is needed today with the support and help of all NHS staff and leaders, politicians, policymakers and the public.”11

But what do they want?Greater citizen involvement in healthcare, while desirable, brings challenges, too. The fact that there are more voices chiming in on healthcare doesn’t necessarily give them greater infl uence in the decision-making process, and one of the headaches for policymakers amid the sound and fury over healthcare reform comes from determining what, exactly, patients want.

While millions of Americans have signed petitions supporting broad principles including cost reductions, guaranteed choice in coverage (including a public insurance option) and quality care for all, many others have expressed concern and even outrage at proposals for a greater government role in healthcare and rising national debt. There are growing expressions of concern about the national fi nancial burden that will be left for future generations.

One of many ironies in the situation is highlighted by the McKinsey analysis, which suggests that many Americans—most often those with employer-provided health coverage—are largely insensitive to costs in their individual healthcare. The situation in the UK is different in the sense that healthcare costs per head are lower and taxpayers know they are footing the bill for the NHS, yet it is still fair to say that most patients do not know what their care actually costs.

The public’s desire for healthcare reform, without clarity about costs and direction, presents clear challenges for policymakers. This year “more people recognise the need for reform, but there’s less agreement on what to do,” says Mary Wilson, president of the League of Women Voters of the US. “We have more buy-in for the concept that something is wrong with the system and it needs to be fi xed.”

Our survey offers some guidance on factors affecting patients’ choice of hospitals (assuming they have a choice) and their willingness to pay more for faster or better service. Although access to the latest

11. The NHS Confederation, Dealing with the Downturn, June 2009.



20

technologies and treatments unsurprisingly tops the list of key factors for patients when choosing a hospital, it is matched by a simple desire for cleanliness and hygiene, in part prompted, perhaps, by fears about hospital-acquired infections. This was followed overall by a desire for clear and timely information (see chart). These hardly seem overly demanding. About one in three respondents overall would be willing to pay (or pay more) to receive good quality hospital treatments, although a greater proportion (42%) are unwilling to pay extra for anything.

As part of this data suggests, the “fi x” for healthcare can be couched to a large extent in national cultural values and norms. Yale’s Professor Marmor, who has written extensively on international health policy, notes that cultural norms infl uence the way that patients express their likes and dislikes. Although British patients are becoming more outspoken as consumers of healthcare, for instance, “you can’t ignore the role of social hierarchy and deference in the English context”. Attitudes towards doctors have changed in recent decades, but he still sees a deference towards them by many patients that is not found in places like the US.

If you had to go to hospital, which of the following factors would be most important to you, assuming you could choose? Please select up to three.(% respondents)

43

US Germany UK IndiaAccess to the latest technologies

and treatmentsClear and timely information from

doctors and/or nursesCaring and supportive nurses

and doctors

Cleanliness and hygiene

Good value for money

General ambience of hospital,including food and comfort

Proven or documented results intreating my condition



65

42

47

16

7

39

2

3

54

57

35

56

12

17

30

1

2

46

51

53

78

1

14

24

1

3

46

59

42

53

25

6

20

0

0


Which of the following would you be willing to pay (more) for, in order to receive a faster and/or higher quality of service? Select up to two.(% respondents)

5

US Germany UK India

Doctor/GP consultations

Waiting time for operations

Quality of hospital staffand environment

Quality of hospitaltreatments/operations

Medicines

Advice on healthcare andpreventive medicine

(eg, via Internet, phone, etc)Other, please specify

None of the above: I wouldnot be willing to pay more

17

21

26

9

5

2

49

9

18

15

33

4

4

1

49

26

14

9

21

9

2

1

51

7

48

26

55

28

11

0

4




21

American politicians across the spectrum have acknowledged that retaining a choice in providers and insurers is important to the American people, whose cultural values tend to favour individual decisions over the sort of collective decision-making that prevails in places like Europe. In general, Americans are used to having a choice in many aspects of life; Europeans perhaps less so.

Indeed, our survey reveals that Americans feel more encouraged to choose from a range of hospitals and doctors for their treatment than people surveyed in other countries, which helps to explain some of the current public concerns about reforms that would reduce their choices. The survey shows that Americans also feel they have much more control and infl uence over how they’re treated than their British counterparts—about seven in ten respondents feel they are encouraged to shop around for doctors and hospitals. In the UK, by contrast, nearly six in ten respondents say they are not.

A recent study by Stanford University’s Center on Longevity on specifi c consumer preferences regarding healthcare reform revealed that there is a good deal of ambivalence among voters on these issues, according to centre director, Professor Laura Carstensen. When presented with a series of detailed healthcare reform proposals, the people polled showed no clear preference12.

The Stanford results revealed that when it comes to healthcare coverage, a majority of Americans are “pretty happy with their own, but they know the system is broken,” says Professor Carstensen. In her view, the results seem to reinforce the status quo. Another signifi cant fi nding was a deep partisan divide over health policy issues: Democrats showed a strong concern for uninsured Americans, whereas Republicans were much more worried about preventing greater government involvement in the healthcare system.

In your country, would you say that people are encouraged to choose from a range of hospitals and/or GPs/physicians for their treatment?(% respondents)

23

US Germany UK India

Yes

No

Don’t know

69

9

39

48

13

58

31

11

20

74

6


US

Germany

UK

India

How strongly do you agree or disagree with the following statement? I feel I have a lot of control and influence over mychoices of where and how I am treated (% respondents)

1

2111730319

1

1

514154321

113231187

23144436



12. Stanford Centre on Longevity, Health Security Project: Building Sensible Health Care Solutions, 2009.



22

Steps forward for patients in the UKHealthcare reform in the UK is unlikely to be on the same scale as that proposed in the US. Nonetheless, two relatively recent strategic reforms may have a more direct, immediate impact on how healthcare is delivered to better meet patient needs. One of them, at least, involves a closer role for patients as part of the process of improving healthcare, as the NHS aims to live up to the “patients as partners” ethos espoused by the former health minister, Lord Darzi.

The NHS’s new patient-reported outcome measures (PROMs) are a tool for compiling patient-reported satisfaction outcomes on specifi c medical procedures. Launched in early 2009, the system is still in its infancy, but the aim is to report health outcomes that are signifi cant to patients, and may differ from what doctors, nurses or NHS managers think are important. In theory, this will lead to a more equitable distribution of health resources.

Indian healthcare: seeking a new route

“India is a goddess with many faces,” says Kavita Ramdas, CEO and president of the Global Fund for Women. The statement rings as true in healthcare as in many other sectors affected by variations in income, education, caste, gender and geography across a country of more than 1bn people.

Rich urbanites (and “medical tourists” from abroad) plump for elective treatments in private clinics, the growing middle class has rising expectations about the quality and speed of its care, and poor Indians (the majority) are served by an overstretched and underfunded network of government-run primary health centres that is woefully short of skilled medical staff, especially in rural areas where 70% of the population lives. The challenges include a shortage of skilled medical personnel, and feeble expenditures on healthcare by some states. Grim statistics on average life expectancy and infant mortality—sobering even by standards in the developing world—reveal how far India lags behind much of the world in health.

Yet the Economist Intelligence Unit’s citizen survey also fi nds glimmers of hope. The Indians surveyed (mostly urban dwellers, more than three-quarters of them with college degrees) were more optimistic than people surveyed in the US, UK or Germany that they would receive “prompt and effective treatment” if they or a member of their family were to be ill. While they expressed more concern than their foreign counterparts about the cost of such care, they also voiced a greater willingness to pay more for better and faster hospital treatment.

The growth of private healthcare providers and insurance plans is one factor improving the outlook and choices for patient care. It may be out of reach for the rural masses in India, but a growing middle class of some 250m people (larger than the combined populations of western Europe’s three biggest countries) is increasingly turning to private care. The government, accordingly, sees the private sector as a key element in its aim to increase the country’s healthcare capacity. As more middle and upper-class Indians get treated privately, more space becomes available in the government health service for poorer people who have no alternatives.

The current government is “fairly bullish”

on healthcare, says Monika Sood of Feedback Ventures, an advisory company that works with government and private clients in the sector, noting campaign pledges to cut the inequalities in care between urban and rural areas. She points to additional funding for a national insurance plan for the poor, and an increasing role for government as a


India

Quality of hospital treatments/operations


Medicines

Quality of hospital staff and environment

Advice on healthcare and preventive medicine(eg, via Internet, phone, etc)


Other

None of the above: I would not be willing to pay more

7

48

26

55

28

11

0

4




23

The rollout of PROMs is expected to have a dramatic impact on how patients and clinicians assess the effectiveness of healthcare. An example of how patient feedback can be used involves cataract patients, who were asked about the change in their quality of life after surgery. Despite the expectations of clinicians that the changes would be profound, about half the cataract patients surveyed said that they had not experienced any improvement in quality of life as a result of surgery. The data, collected for the UK’s Department of Health, found that many of them in fact had a fairly good quality of life before their operations. The result raised questions about how high a priority cataract surgery should be going forward.

“If the NHS has switched from making Trabants to Rolls Royces […] we’re still only counting cars,” says Professor Appleby of The King’s Fund. But PROMs, he adds, can show healthcare administrators where productivity improvements are most needed. Measuring patients’ views of the impact of treatment on their own health will in turn show where the NHS is making the greatest impact. Initially, the tool will

buyer of healthcare services—not simply as a provider—as indications of its willingness to become more active in the sector.

Still, there are limits on how far the government can go. One issue is funding: Rajat Gupta, who was instrumental in setting up the Public Health Foundation of India, has noted that spending on hospital infrastructure will probably only increase by 2% per year over the next decade13.

While there is clearly a temptation to encourage more private-sector development, savvy offi cials also recognise the politically tricky nature of privatising health services, especially given the tradition of free government healthcare. Ten years ago, “the mindset was ‘healthcare is free’,” said Ms Sood. Now there is a greater willingness to pay for quality care, as borne out by our survey: more than half (55%) of Indian respondents stated they would pay more for better quality hospital treatments, and nearly as many (48%) would do the same for better doctor consultations.

Offi cials, though, are still wary of touching the core of the free system. Privatisation efforts have instead focused on allowing the private sector to operate new hospitals with the government supplying the buildings,

offering “greenfi eld routes” with public land provided for private investors to build and operate health facilities.

Tensions remain, though: one current problem is the drift of doctors to the private sector, where they can earn four or fi ve times as much money. Moreover, the knotty problem of underserved rural areas—the least appealing assignments for many doctors—remains. Rural women are especially affected, as they and their families regard their health as a low priority for the family—a contributing factor in India’s high rate of maternal mortality. While the government is encouraging more private-sector investment in rural and semi-urban areas, it is unlikely that rural areas will ever be adequately served by private fi rms. “Health is one area where it can’t just be left to the private sector,” says Ms Sood.

Anasuya Sengupta, Asia and Oceania director of the Global Fund for Women, says rural populations face particular challenges with access, awareness and accountability in healthcare. Accordingly, more non-government entities, citizens’ groups and communities are taking matters into their own hands, emboldened by past successes in pressuring the government on issues like HIV/AIDS. The state government of Karnataka,

the Indian Institute of Management and a local non-profi t group, for instance, have collaborated to bring theatre performances to rural villages, trying to raise awareness about health issues and encourage local dialogue. A growing number of community groups, as well as medical staff, are supporting such outreach efforts as a way to reach the poor, uneducated and most vulnerable Indians.

Amid the many challenges, there are other signs of hope. Mr Gupta claims India is well-placed to tackle its health challenges for two key reasons: it can learn from and avoid “the costly errors” of more advanced economies, and create its own, new models by integrating the strengths of business and the non-profi t sector. Ms Sood concurs that there are lessons to be learned. “In the US, there was a lot of money available for healthcare. Investment went into things like diagnostics. Insurance rates are also driving the US, and the result is fairly high costs of healthcare delivery,” she says. In India, where pricing is an important variable in uptake of services, policymakers are asking how they can avoid some of those pitfalls. “In India we’re wondering how we ensure we don’t face the same issues the US is facing today.”

13. McKinsey Quarterly, A Healthier Future for India, January 2008.



24

be used to assess just a handful of common procedures—involving hips, knees, cataracts and varicose veins—but proponents are understandably pushing for an expansion into other areas as well. For a public that tends to assume a degree of relatively consistent quality across the system, the results could be a real eye-opener.

A more established NHS procedure, aimed at offering a sort of best-buy guide for healthcare products and services, is the National Institute for Clinical Excellence (NICE). The goal of this body, set up a decade ago, is methodically and independently to assess the value for money of different approaches. The goal is to make NHS decision-making more transparent and public. When patients want to challenge its judgements—about payment for cancer drugs, for instance, or limits on end-of-life care—they have an ability to take their cases to court. While this is a useful mechanism for keeping a lid on costs, the political reality has at times been too much to bear. The uproar surrounding certain contested cases has meant that NICE’s standards for end-of-life care have been relaxed under pressure; in February this year, for example, NICE was forced to reverse a decision it had made and to allow the cancer drug, Sutent, to be used on the NHS.

This political reality—the hard trade-offs that policymakers face—can undercut even the most carefully crafted strategy. Indeed, by the time Lord Darzi resigned as health minister to focus solely on his medical work, some were questioning whether his focus on quality was at odds with the government’s focus on targets. The grand bargain that policymakers must strike with the public over healthcare is not an easy one in these diffi cult times. This is as true in countries like the US and UK as it is in strikingly different markets, such as India (see box, Indian healthcare: seeking a new route).



25

The challenge for policymakers is how to strike a grand bargain with patients who are no longer passive recipients of care, and are increasingly active consumers of health services. Patients are

armed with more information, new networks and outlets to make their voices heard, and a greater sense of entitlement than ever before. Will policymakers be able to set a course that maintains (or preferably improves) current standards of care as demanded by patients without going further into debt?

Such a grand bargain is possible, but challenges loom. The fi rst is a disconnect between consumers and policymakers on the need for radical reform. The latter face an immediate and escalating fi nancial dilemma. Meanwhile, consumers have complaints about their own care and the way governments are handling health policy, but when push comes to shove, fears about losing what they currently have—whether it’s an American insurance plan or a British NHS programme—outweigh the desire for major systemic change for many consumers. This is partly attributable to the hidden costs of the current health system. Neither Americans who are covered by employer-backed insurance plans nor Britons getting care through the NHS see the true costs of their current care, or the risks of inaction by policymakers.

Given that such risks are real, reform is indeed desirable. A second challenge is how then to make it palatable to consumers. Efforts at reform should start promptly and policymakers will need to change the language they are using with the public. The need for prompt action in some countries is driven not only by an increasingly bleak fi nancial picture, but also by the political calendar. A general election in the UK—to be called by June 2010—and US congressional elections in November 2010 will affect politicians’ willingness to advocate bold action in those countries. As elections draw closer, the window of opportunity for signifi cant reform will narrow and then close. Even then, the German experience shows that reforms can take years to work their way through a healthcare system.

To be most effective, policymakers must link patients’ personal healthcare experiences with a demonstrated ability to see improvements in treatment. The UK is taking steps in this direction with PROMs, a programme designed to improve care in ways that are most meaningful to patients, and shift limited healthcare resources accordingly. PROMs is still in its infancy, and thus far narrowly focused on a handful of procedures, but the concept is a good one. It is designed to measure what patients, not necessarily payers or providers, value most.

To succeed, reform initiatives should also align incentives to pay for value and outcomes, not quantity of care. In the US, for instance, fi nancial incentives are aligned to promote cancer screening technologies that result in good health outcomes and also save money in the long run. In the UK, if admission to

Conclusion—Policymakers’ grand bargain



26

hospital were treated as a failure and incentives aligned accordingly, for instance, it would put pressure on the system to invest in preventive care and more cost-effective treatment methods.

Finally, a move towards more integrated care would also help to bridge the disconnect between patients and policymakers. In order to put patients fi rst, some of the traditional walls that have historically separated primary and secondary care should come down. The result, although challenging clinicians to realign the way they work, would improve the patient experience while reducing ineffi ciencies and administrative costs.

The particular ways in which reforms are pursued—and the language used to sell them to the public—will undoubtedly differ from country to country, not least because of their different starting points. They will only succeed if policymakers take national social norms and values into account. The underlying challenges are remarkably similar though, and given what is at stake, policymakers cannot afford to duck their responsibilities in trying to strike a grand bargain.


Appendix Survey results


27

Appendix: Survey results

US

Germany

UK

India

Are you male or female? (% respondents)

45

53

52

49

55

47

48

51

Male Female

What age group do you fall into? (% respondents)

Younger than 18

18-25

26-35

36-45

46-55

56-65

66-75

Older than 75

0

11

4

7

15

28

30

5

0 0 0

9 6 19

13 16 29

18 16 33

20 15 15

8 27 1

30 18 4

1 3 0

US Germany UK India

Which of the following best describes your employment status?(% respondents)

Full-time employed

Part-time employed/freelance

Unemployed

Student

Retired

25

14

18

5

39

42

11

19

5

23

33

11

15

3

38

67

15

8

7

2

US Germany UK India

28 © Economist Intelligence Unit Limited 2009

AppendixSurvey results


Which of the following best describes your highest level of education?(% respondents)

1

19

40

30

9

2

54

22

12

3

8

0

20

14

39

18

7

2

1

3

8

48

37

3

US Germany UK IndiaSome primary and/orsecondary schooling

High school graduateSome college/technical/

graduate studies,but no degree

Bachelors degree

Masters degree

Doctorate degree

If you had to vote tomorrow, which of the following issues would be most important to you, in terms of your government’s priorities? Please select up to two.(% respondents)

Crime

Economy and jobs

Education

Healthcare

Environment andclimate change

Defence and terrorism

Housing


8

67

5

39

9

19

2

8

12

76

18

48

17

4

2

5

37

57

11

31

12

13

6

6

14

52

28

44

14

18

2

3

US Germany UK India

If you or a member of your family fell seriously ill, how optimistic are you that they would receive prompt and effective treatment?(% respondents)

42

US Germany UK India

Very optimistic

Somewhat optimistic

Neither optimisticnor pessimistic

Somewhat pessimistic

Very pessimistic

Don’t know what qualityof treatment would

be received

32

10

9

3

4

30

8

33

16

6

7

42

19

22

12

4

1

35

44

9

4

1

4




29

If you or a member of your family fell seriously ill, how concerned would you be about the costs of ensuring they received prompt and effective treatment?(% respondents)

33

US Germany UK India

Very concerned

Somewhat concerned

Neither concerned norunconcerned

Not all that concerned

Not concerned at all

Don’t know how costswould be affected

41

9

8

5

4

40

15

20

15

4

5

33

16

18

16

11

6

23

61

6

3

4

2

In your country, would you say that people are encouraged to choose from a range of hospitals and/or GPs/physicians for their treatment?(% respondents)

23

US Germany UK India

Yes

No

Don’t know

69

9

39

48

13

58

31

11

20

74

6

If the choice existed, would you compare services at a range of hospitals and/or GPs/physicians in order to get the best possible treatment?(% respondents)

7

US Germany UK India

Yes

No

Don’t know

81

12

5

89

6

11

75

14

5

89

6

US

Germany

UK

India

How strongly do you agree or disagree with the following statement? My health is my own responsibility(% respondents)

1394444

112154536

12105136

242866





US

Germany

UK

India

How strongly do you agree or disagree with the following statement? The pay of healthcare professionals should be linkedto their performance (% respondents)

1

1

14194530

35124731

339234320

11475335


US

Germany

UK

India

How strongly do you agree or disagree with the following statement? Healthcare professionals work too many hours to betruly effective in their jobs (% respondents)

332040288

23154338

21112842

22102640

15

21


What are the biggest barriers for you in terms of living in a healthy way (thinking about your current level of health)?(% respondents)

8

US Germany UK India

Don’t know what to do

Not enough time

Not enough money

Lack of willpower


Don’t know what stopsme from securing my

long-term health

6

38

29

10

9

20

9

43

21

4

3

11

5

37

30

10

8

36

9

28

18

5

6

Which of the following sources do you regularly consult for health information? Select all that apply.(% respondents)

8

My doctor

TV/radio

Magazines/newspapers

Specialist healthcarewebsites

General Internetsearches

My family and friends

Patient groups


Don’t know what thebest sources of

information are

76

14

32

32

31

2

6

6

39

58

48

28

39

31

7

3

5

10

62

15

28

33

29

3

8

8

29

73

47

29

33

50

2

1

3

US Germany UK India




31

Which of the following parties do you believe should have automatic access to your patient data and history of access to healthcare? Select all that apply.(% respondents)

39

Only myself and thoseI have pre-authorised

Hospitals

Receptionists

Nurses

GPs/physicians

Insurers

Government

No one

80

2

15

39

9

1

2

52

12

36

5

7

55

4

0

68

53

4

27

76

4

3

2

48

64

5

8

29

21

18

2

US Germany UK India

Which of the following aspects of your country’s healthcare system are you satisfied with? Select all that apply.(% respondents)

Waiting times for operations

Quality and availability ofhealthcare informationQuality and availability

of healthcare

Quality of your GP/physician

The cost of medicine

The cost of hospital treatment

State/government-sourcedhealth advice and campaigns


None of the above

Don’t know

US Germany UK India

46

30

45

52

11

7

5

1

24

6

33

21

28

59

10

12

8

0

20

5

33

18

36

63

27

30

19

1

15

5

35

18

45

32

35

30

24

1

12

3

If you had to go to hospital, which of the following factors would be most important to you, assuming you could choose? Please select up to three.(% respondents)

43

US Germany UK IndiaAccess to the latest technologies

and treatmentsClear and timely information from

doctors and/or nursesCaring and supportive nurses

and doctors

Cleanliness and hygiene

Good value for money

General ambience of hospital,including food and comfort

Proven or documented results intreating my condition



65

42

47

16

7

39

2

3

54

57

35

56

12

17

30

1

2

46

51

53

78

1

14

24

1

3

46

59

42

53

25

6

20

0

0





5

US Germany UK India



Quality of hospital staffand environment

Quality of hospitaltreatments/operations

Medicines

Advice on healthcare andpreventive medicine

(eg, via Internet, phone, etc)Other, please specify

None of the above: I wouldnot be willing to pay more

17

21

26

9

5

2

49

9

18

15

33

4

4

1

49

26

14

9

21

9

2

1

51

7

48

26

55

28

11

0

4

US

Germany

UK

India

How strongly do you agree or disagree with the following statement? My country’s government has the right approach tohealthcare (% respondents)

427

430

223494

332662

2122532227

11118303010


In which ways would you be most willing to pay (more) for an improved healthcare service? Select up to two.(% respondents)

14

US Germany UK India

Increased taxes

(Increased) fees at thepoint of provision

(Increased) fees tohealthcare insurer

None of the above: I amnot willing to pay more

I have no opinion

15

11

61

7

12

9

12

64

6

13

27

11

45

10

36

21

40

23

11

US

Germany

UK

India

How strongly do you agree or disagree with the following statement? I feel I have a lot of control and influence over mychoices of where and how I am treated (% respondents)

1

2111730319

1

1

514154321

113231187

23144436





33

US

Germany

UK

India

How strongly do you agree or disagree with the following statement? A greater role by private operators would improve mycountry's healthcare system (% respondents)

8111435258

8101632269

6132136194

137154925


US

Germany

UK

India

In your opinion, should the government takes steps, and if necessary pass laws on, particular activities (eg, smoking, drinkingetc) in order to encourage people to adopt healthier lifestyles? (% respondents)

115435

74548

93853

11287

Yes No Don’t know

Which of the following things do you believe your government has done a good job of implementing and/or promoting? Select up to three. (% respondents)

32

US Germany UK IndiaBanning and enforcement of

smoking in public placesBanning of cigarette and

alcohol-related advertisingBanning of direct marketing of fast food to children

(eg, TV advertising, school vending machines)Raising public awareness of behavioural

risks (eg, alcohol, driving, drugs)Encouraging me to have regular

medical check-upsEncouraging and/or subsidising

vaccinationsEncouraging a healthy diet

and active lifestyle


None of the above

Don’t know what thegovernment has done

51

13

42

13

17

21

1

13

5

42

49

22

32

23

18

15

0

12

4

41

67

27

38

11

18

19

1

9

5

52

73

13

47

14

33

10

1

2

2

Whilst every effort has been made to verify the accuracy of this information, neither the Economist Intelligence Unit Ltd nor the sponsors of this report can accept any responsibility for liability for reliance by any person on this report or any other information, opinions or conclusions set out herein.Co

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